Impact of Disposition on Outcomes and Utilization on ED Chest Pain Patients

Background

Within the US, chest pain is the most common etiology for observation and short inpatient stays.Patients are admitted to assess for the presence of serious pathology including acute coronary syndrome (ACS). To decrease short inpatient stays, institutions have transitioned to observational status and those patients are considered outpatients. The impact of this change on resource utilization and patient outcomes continues to be unclear.

Clinical Question

What is the effect of placing an adult chest pain patient in observation on healthcare utilization (angiography, PCI, rehospitalization) and on 30-day acute MI as compared to a short inpatient admission.

Population

All patients > 18 years of age who presented to an ED with a primary diagnosis of acute chest pain based on ICD-9 codes who were placed in observation, admitted for < 2 days or discharged home. The data source was OptumLabs Data Warehouse, a database from privately insured and Medicare advantage enrollees throughout the US from Jan 1, 2010 and Dec 31, 2014

Outcomes

Healthcare utilization within 30 days (defined as invasive procedures – coronary angiography, PCI or CABG)
Hospitalization within 30 days
Acute Myocardial Infarction within 30 days

Author's Conclusions

“There were higher rates of cardiac catheterization and PCI among those admitted as a short inpatient compared to observation, while the incidence of subsequent AMI within 30 days was similar”

Our Conclusions

We agree with the authors conclusions that in this study, short term admission was associated to higher advanced treatment utilization without improving outcomes. However, a randomized trial is necessary to demonstrate causality.

Bottom Line

Patients admitted to higher level of care received “more care” but not necessarily better care. The additional care seen in this cohort did not result in better patient outcomes.